Effective
communication
with service
users
Ghazala Mir
A Race Equality Foundation
Briefing Paper
March 2007
Better
Health
4
3
1
2
Key messages
Information about services should be available in a range of languages and formats
Employing staff from minority ethnic communities at all levels of an organisation increases cultural competence within it
Families may need to be involved in the communication process Effective communication requires action at the institutional as well as individual level
Introduction
Communication between service providers and people from minority ethnic communities has been highlighted as significant in many studies on inequalities in health and social care. National policies relating to health inequalities and to patient choice also emphasise a need for effective communication between professionals and service users (Department of Health 2001; 2002). Achieving this policy aim requires an understanding that expectations and assumptions, which are rooted in values and beliefs, play an important role in the communication process (Lago and Thompson 1996). The evidence shows that poor levels of communication have a negative effect on access to services and on relationships between service users and professionals. Problems with communication include language barriers and poor engagement with networks used by minority ethnic groups (Betancourt
et al, 2002). There is also evidence of a lack of confidence or willingness on the part of both service providers and users to discuss cultural issues that may be relevant to the way services are provided. For example, how a person’s normal diet might fit with a recommended diet; how to take medication when fasting or travelling abroad; or how language or gender-related needs might be met (Mir and Din, 2003).
Much of the evidence on
effective communication is
to be found in wider
studies about ethnicity,
health and social care.
The following websites
provide a range of
resources that will be
helpful in understanding
how communication
relates to these wider
issues. They also highlight
practical ways in which
professionals have tried to
improve service provision
for minority ethnic
communities.
Kings Fund website
www.kingsfund.org.uk/health_
topics/black_and.html
The King’s Fund has a
programme of work
focused on black and
minority ethnic groups that
includes evidence about
inequities in access to
health care.
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relationships. They may also not raise issues that affect them because they do not expect these to be understood (Mir and Din, 2003).
Failing to communicate effectively can create a vacuum in accurate knowledge about service users from minority ethnic communities. This can result in professionals falling back on stereotypes and assumptions that compromise the quality and effectiveness of services provided. Service users can perceive poor communication as an apparent disinterest in their welfare, leading to mistrust of both the service and the provider (Katbamna et al, 2000; Mir and Din, 2003).
The research evidence on communication is focused mainly on studies in South Asian populations, and there are gaps in the evidence relating to other minority ethnic groups. Where studies include a range of communities, however, common experiences are often found between different communities.
Information about services should be available in a range of languages
and formats
People from minority ethnic communities are often unaware that services are available because they have never seen or heard information about them (Katbamna et al, 2000). Using a single approach to reach minority ethnic groups does not work for the same reasons it would not work in the general population. For example, if talks to community groups were the only means of telling people about a campaign to stop smoking, the information would reach a relatively small number of people (Mir and Din, 2003), many of whom might not be smokers, as the majority would not belong to community groups. Written information, a telephone helpline, outreach activities and a media campaign could together form a communication strategy that would be much more effective. As part of this strategy, language support would need to be addressed (Aspinall and Jackson, 2004). This should include the language needs of African and Caribbean communities, which are often overlooked (Robinson, 1998).
Access to written information can be vital. For example, people who have been newly diagnosed with a heart condition may be given detailed information packs about how to maintain a healthy lifestyle, to which they may need to refer at various times. If they are unable to access the
information within it because they cannot read English they are more likely to
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experience complications and earlier mortality (Mir and Din, 2003). Using translated material in everyday language can remove this barrier to communication, prevent avoidable suffering and reduce the costs of healthcare (Katbamna et al, 2000; Mir and Din, 2003; Robinson 2002). Making English language materials easy to read and including pictures can also improve access for many people from minority ethnic communities, as well as people with limited literacy and people with learning disabilities (Aspinall and Jackson, 2004; Mir et al2001; Robinson, 2002). Adapting materials to reflect relevant cultural practices, such as diet, will also help make them more appropriate (Mir and Din, 2003).
However, if a person is not literate in his or her own language, access to a professional who can give verbal advice in an appropriate language is needed (Betancourt et al, 2002). Access to this person should be as easy as
possible and should not rely only on professional referral (Mir and Din, 2003). Posters, leaflets and outreach activity that advertise this support need to be made widely available through networks used by minority ethnic
communities. For example, via community centres, places of worship and local shops, or services used by members of these communities (Aspinall and Jackson, 2004).
Employing staff from minority ethnic communities at all levels of an
organisation increases cultural competence within it
Research evidence shows that interpreting by family members, rather than professional interpreters, can result in poor levels of communication with service users and unethical practices (Mir et al, 2001). Poor practice includes using children as interpreters or placing an unacceptable emotional burden on the person doing the interpreting and creating tensions between close
relatives (Katbamna et al2000).
Organising appointment systems to make the best use of such support facilities can reduce costs and make the service more accessible to people who need it (Mir and Din, 2002).
Interpreting is no substitute for direct communication, which is preferred by professionals and service users alike (Mir and Din, 2002; Robinson, 2002). Recruiting bilingual staff into mainstream healthcare enables more direct communication between patients and professionals and can help ensure that the workforce reflects the population served (Katbamna et al, 2000; Mir et al, 2001). Those who are responsible for such appointments should make sure they are able to test language ability and that they include skilled people from relevant communities on appointment panels. Attitudes towards diversity should be tested in such appointments in the same way as for all staff to ensure that individuals will help promote good relationships with service users (Mir and Din, 2003).
Recruiting people to reflect the make-up of the population served can also improve cultural competence within the organisation. Individuals who have relevant skills and knowledge in this area can pass these on to colleagues through informal and formal training and help challenge any stereotypes or negative attitudes that may exist within service teams (Mir et al, 2001). It should not be assumed, however, that people will automatically have such skills just because they are from a minority ethnic community. The grade at which appointments are made is likely to be a factor in the level of support that people might need to develop this kind of role (Robinson, 2002). Increased employment of people from some minority ethnic communities has the added benefit of addressing the higher unemployment levels they experience. This strategy communicates powerful message of social inclusion to people from these groups, including service users. Both employment and social inclusion are linked to health status and health inequalities (Mir and Din. 2003).
Once people from minority ethnic communities form part of the workforce it is important to ensure they are properly supported to do the work for which they have been employed. If they are expected to take on a casework role, it will be important to make sure they are not the only members of staff dealing with service users from minority ethnic groups (Betancourt et al, 2002). Otherwise, service users from these groups may not have access to the full range of opportunities open to everyone else (Mir et al, 2001). If staff are expected to take on a strategic role, they will need to be employed at an appropriate grade and have the authority and connections to make sure a strategy can be
Race for Health
www.raceforhealth.org
Race for Health is a
programme to support a
network of Primary Care
Trusts (PCTs) around the
country, working in
partnership with local black
and minority ethnic
communities to improve
health, modernise services,
increase choice and create
greater diversity within the
NHS workforce. The first
13 PCTs involved are now
being joined by another 13.
Expert Patients
Programme
www.expertpatients.nhs.uk
The Expert Patients
Programme is an NHS
self-management programme
delivered by lay people for
anyone living with any long
term health condition(s).
The aim is to give
participants confidence to
take responsibility for their
own care, while also
encouraging them to work
in partnership with health
and social care
professionals.
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implemented (Betancourt et al, 2002). Giving the strategy a high profile and training the whole workforce is important so that this is seen as everyone’s responsibility. Use of minority ethnic workers should not be seen as a substitute for training other staff in cultural awareness (Burford et al, 2000).
Families may need to be involved in the communication process
Engaging with families is important to an accurate understanding of their circumstances. The myth of extended family support networks for South Asian people, for example, is perpetuated by agencies failing to investigate the circumstances of family carers. South Asian families are shown by research to need family support as much as other families (Ward, 2001; Katbamna et al, 2000).
Family dynamics may need to be addressed when individuals require support to follow professional advice. For example, where there is poor family support for changes to diet and lifestyle, investing time to arrive at negotiated ways forward with key family members could lead to significantly improved support for some service users (Mir and Din, 2003).
In communities that place a high value on collectivity and interdependence, families can play a vital role in decision-making. The low status often given to a collectivist philosophy by mainstream services, however, can place them in direct conflict with families, hampering trust and the ability to work in partnership (Bignall and Butt, 2000; Mir et al, 2001).
Access to service provision can be improved through addressing attitudes within families and communities towards opportunities provided by these services. One study found that Chinese families associated use of services with poverty and this perception acted as a disincentive to take-up (Nothard, 1993). There may be concerns within families about the type of support provided, whether this would be appropriate in relation to the family’s culture or religion, and worries about the safety of an individual who may be vulnerable (Mir et al2001; Bignall and Butt, 2000).
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can usually be improved and family members value the opportunities provided (Mir et al, 2001). Whereas respecting an individual’s independence is important, a focus on independence has sometimes proved to be a convenient pretext for undermining minority cultures. The key to widening opportunities available to people from minority ethnic communities lies in respecting cultural identity rather than in persuading individuals and families that the majority culture is necessarily better (Mir et al, 2001).
At the same time, respecting cultural diversity should not be confused with supporting oppressive family practices (Bignall and Butt, 2000). Pursuing a balanced approach is not easy for professionals but lack of balance can alienate service users, families or both. It can be helpful for professionals to seek advice from relevant community organisations, where expertise in culturally appropriate interventions is most often found (Mir et al, 2001).
Effective communication requires action at the institutional as well as
individual level
At an institutional level, service providers need to ensure that the workforce is motivated and equipped to communicate effectively with people from minority ethnic communities. Institutional policies and procedures should be assessed for their impact on people from these groups (Burford et al, 2000). For example, procedures to determine the needs of a service user should be reviewed to ensure these are not culturally biased towards Western lifestyles and take account of other cultural traditions (Betancourt et al, 2002). Policies and procedures should demonstrate an expectation of effective
communication skills from staff at all levels and set out opportunities for training and partnerships that will support the development of this kind of competence in the organisation (Audit Commission, 2004).
Organisations need to gather information about and from minority ethnic communities as well as trying to provide information to them. Effective methods for identifying the needs of people from these communities and monitoring how well these are met are needed; collecting information about the make-up of populations served by means of published data and effective monitoring can highlight which groups an organisation may be neglecting and which may be over- represented (Audit Commission, 2004). In rural areas, small populations of people from minority ethnic communities may need particular attention as they are often dispersed and face greater levels of neglect (see Rural Diversity website in the Resources column).
Transcultural Health Care
Practice
www.rcn.org.uk/resources/
transcultural
This is an educational
resource for nurses and
health care practitioners.
Ethnicity and Learning
Disability
http://valuingpeople.gov.uk/
dynamic/valuingpeople86.jsp
This website has resources
that can help address the
multiple discrimination that
people with learning
disabilities experience.
Delivering race equality
www.dh.gov.uk
This is a five-year action
plan for tackling
discrimination in NHS and
local authority mental
Apart from ethnic group, monitoring the religion and language of service users can give a fuller picture of potential needs and show whether the workforce accurately reflects all groups within the local population (Aspinall and Jackson, 2004). It is also vital that service providers consult people from these
populations about the kinds of services they need and ensure they have a voice in decision making about provision (Betancourt et al, 2002).
Partnerships with voluntary sector organisations that represent the interests of these groups, can help transfer cultural competence that is often located in community organisations to mainstream settings. Such groups will need to be developed in areas where they do not already exist (Mir and Tovey, 2002). Collecting this kind of information is only really useful if the gaps identified are then used to inform the commissioning and planning process. Matching information about needs to commissioning processes effectively targets resources where they are most needed and can prevent inequalities widening. It can also prevent expensive mistakes, such as providing resources in inappropriate languages or employing staff who do not have the skills needed to engage with communities that need specific targeting (Mir and Din, 2003). Two important measures of cultural competence within an organisation are service user satisfaction and service user outcomes (Betancourt et al2002). Measuring these across ethnic, religious and language groups can help a provider understand where future work needs to be targeted (Audit
Examples of good practice
Equipping staff with relevant skills
Bradford City Teaching Primary Care Trust’s speech and language therapy service has therapists specialising in bilingualism. They can deliver support in Punjabi — the most sought-after of the local community languages — as well as in Urdu and Bengali. The unit is also developing a capacity for Eastern
European languages.
The service records information on Compact Disc (CD) and audio cassettes to help families support children with speech and language development. The CD also explains what speech therapists do so that parents understand the service before they go to the clinic. Of the unit’s forty-three staff, thirty are learning Urdu including managers, therapists and clerical staff, so that they can effectively deliver the service to people in the local area. Urdu lessons are tailored to suit therapists’needs and are accompanied by a specially recorded CD with which team members can practice.
Making services accessible and appropriate
The London Borough of Tower Hamlets recognised that take-up of services by people with visual impairment from minority groups has been an acute
problem. A study commissioned by the borough found cultural issues needed to be acknowledged and addressed. The borough appointed a bilingual development officer who herself had a visual impairment. Her background and life experience provided a crucial link to the Bangladeshi community.
The project developed outreach activities to give families basic information about a range of services they could access easily. This developed into weekly information and advice surgeries and training to community and religious groups. The improved access to services has at times made huge differences to the quality of life that people involved with the project experienced.
Rural Diversity
www.ruraldiversity.org/index.htm
This website has
information and resources
on rural race equality.
Further reading
An extensive range of
references and websites
can also be found in:
Bhopal, R. (2007) Ethnicity,
Race and Health in
Multicultural Societies:
Foundations for better
epidemiology, public health
and health care, Oxford:
Meaningful consultation
Westminster Primary Care Trust (PCT) has set up a Black and Minority Ethnic Health Forum, an arms-length advisory group which aims to influence both Westminster and Kensington and Chelsea Primary Care Trusts. The Forum holds regular meetings with local groups and the two boroughs’primary care trusts, hospitals, mental health trusts and social services departments. Using its links with more than 300 community groups and voluntary agencies in the local area the Forum has created a new way for the Trust to listen to the experiences of local black and ethnic minority people. Community groups are involved in planning and executing the process and have been producing the results of consultation with service users on mental health services. This approach worked because people felt the structure and method of consultation had been decided by them rather than imposed.
People from local groups were offered a two-day training session to equip them to run the consultation and the PCT provided interpreters and note-takers as well as meeting rooms and refreshments at the consultation meetings. The events were used to explore people’s experiences of mental health services, their attitudes to mental well-being and their access to information. These were then fed back to the Forum and used to influence planning decisions within the Trust.
Linking data collection to commissioning
Lambeth PCT has joined forces with the Department of General Practice at Guy’s, King’s and St.Thomas’School of Medicine and the South London Primary Care Research Network to improve data collection of ethnicity, language and religion in general practices. In one project connected with this exercise, data gathered will be used to examine the difference in prevalence of psychosis between the African-Caribbean and general populations. It will look at access to services and barriers to access and develop service modifications to address these. In the long run, the PCT hopes to be able to do equity audits on a large number of health care activities. It expects that in time, lots of small
Conclusion
Where attention is paid to effective communication with minority ethnic service users, substantial progress can be made, as the examples illustrate. Workforce representation and training, family participation and institutional policies are needed to achieve levels of communication that result in access to good quality services. It is important that examples of good practice become routine and widespread; the costs of problems caused by poor communication can be high in human terms — and can lead to expensive litigation (Thorlby and Curry, 2006).
• Aspinall, P. and Jackson, B. (2004) Ethnic Disparities in Health and Health Care: A focused review and
selected examples of good practice, London: Department of Health/London Health Observatory. • Audit Commission (2004) Journey to Race Equality: Delivering improved services to local communities,
London: Audit Commission.
• Betancourt, J., Green, A. and Carrillo, J. (2002) Cultural Competence In Health Care: Emerging Frameworks And Practical Approaches, The Commonwealth Fund.
• Bignall, T. and Butt, J. (2000) Between Ambition and Achievement: Young black disabled people’s views
and experiences of independence and independent living, Bristol: Policy Press/Joseph Rowntree Foundation.
• Burford, B., Bullas, S. and Collier, B. (2000) Positively Diverse Report 2000, London: Department of
Health/ NHS Executive.
• Department of Health (2000) The NHS Plan. A Plan for Investment. A Plan for Reform, (Cmnd 4818-1),
London: The Stationery Office.
• Department of Health/HM Treasury (2002) Tackling Health Inequalities: Cross Cutting Review, London: Department of Health/HM Treasury.
• Katbamna, S., Bhakta, P. and Parker, G. (2000) ‘Perceptions of disability and care-giving relationships in
South Asian communities’ in Ahmad, W (ed.) Ethnicity, Disability and Chronic Illness, Buckingham, Open
University Press.
• Lago, C. and Thompson, J. (1996) Race, Culture and Counselling, Buckingham: Open University Press.
• Mir, G. and Din, I. (2003)Communication, Knowledge and Chronic Illness in the Pakistani Community,
Leeds: Centre for Research in Primary Care, University of Leeds.
• Mir, G., Nocon, A. and Ahmad, W. (2001) Learning Difficulties and Ethnicity, London: Department of Health.
• Mir, G, and Tovey, P (2002) ‘Cultural competency: professional action and South Asian carers’ Journal of
Management in Medicine,16, 1, April, pp. 7-19.
• Nothard, A. (1993) Uptake of services for people with learning disabilities from Black and minority ethnic
communities in Leeds. Leeds: Information and Resources Section, St Mary’s Hospital, Leeds Community
and Mental Health Unit.
• Robinson, L (1998)‘Race’, Communication and the Caring Professions, Buckingham: Open University
Press
• Robinson, M. (2002)Communication and Health in a Multi-ethnic Society. Bristol: Policy Press.
• The Stationery Office (2000) Race Relations (Amendment) Act 2000, London: The Stationery Office.
• Thorlby, R. and Curry, N (2006) Valuing Equality: paper for the National Race for Health Conference 22-23
November 2006. London: King’s Fund/race for health/NHS
www.kingsfund.org.uk/health_topics/black_and.html (last accessed 6 March 2006).
• Ward, C. (2001) Family Matters: Counting Families In London: Department of Health.
Race Equality Foundation
Unit 35
Kings Exchange
Tileyard Road
London N7 9AH
T: 020 7619 6220 F: 020 7619 6230
www.raceequalityfoundation.org.uk
Ghazala Miris a Senior Research
Fellow and Director of the Ethnicity
Training Network in the Centre for
Health and Social Care at the
University of Leeds. Her research
focuses on inequalities in health and
social care experienced by people
from minority ethnic communities and
people with learning disabilities.
Readers
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We welcome feedback on this paper
and on all aspects of our work.
Please email
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